Analysis Decision to Enter Port After a telephone conversation with the company operations manager, and in view of the adverse weather in the area, the master elected to put in at Liverpool. Even though he did not have a detailed marine chart on hand, he decided to put in at Liverpool Harbour, assuming that he could use visual references in the way of range lights, which had been mentioned by an acquaintance, and buoys. Using the global positioning system, a radar and a small-scale chart, the master was on the lookout for presumed range lights and buoys to guide him to the harbour entrance. But when the tug was within the harbour approaches, no range lights could be seen to guide the tug because none exist to facilitate the entrance to Liverpool Harbour. Nearly all of the master's experience was gained in the same physical environment. The nature of his work and the environment in the port of Dalhousie did not offer him the opportunity to increase and diversify his field of professional knowledge. He was on one of his first voyages outside his area of local knowledge. His lack of experience outside his home port and inadequate knowledge of BRM greatly diminished his chances of safely completing the voyage. The master's decision was influenced primarily by the suggestion of the operations manager. However, the master should have informed him clearly that he did not have adequate references to enter Liverpool Harbour. Use of Marine Charts Small-scale charts are intended for offshore navigation only. They contain enough detail, but they only allow the mariner to locate harbour approaches. Approaches are made on a large-scale chart with an inset showing a detailed plan of the harbour, as recommended in the Charts and Nautical Publications Regulations.5 Although large-scale charts covering the Liverpool Harbour area are published, these were not on board and, therefore, could not be used. The basic principles of seamanship require that a vessel should not attempt to enter a port without the largest-scale current marine chart of the area. Lack of Training in Bridge Resource Management A careful watch over the movement of a vessel is indispensable to safe navigation in confined waters. Time is a very important factor in the execution of vessel manoeuvres. It is essential, therefore, that each member of the bridge personnel clearly understands his/her role and ensures that all information significant for the conduct of the vessel is promptly conveyed to the person charged with pilotage or navigation. Because the first mate was not on the bridge, the master was on his own. Deprived of the support of an effective team, the master was left with little room for error. Situational Awareness Situational awareness means having an accurate perception of the factors and conditions that affect the behaviour of a vessel and its crew over a given period of time. In simpler terms, it means knowing what is happening around you. Safe completion of a voyage depends on the level of situational awareness of the person who has the conduct of the vessel. Ease and quality of communication are essential if optimum situational awareness is to be maintained. It is essential that each member of the bridge personnel does everything possible to support the person in charge and maximizes that person's situational awareness. The master of the KetaV did not make use of all the information available to him to make an accurate assessment of the situation. Knowing that he did not have a chart of the appropriate scale, he did not refer to Sailing Directions, which was on board and does not mention range lights appropriate for the approach to Liverpool Harbour. Also, he did not make adequate use of navigational instruments, particularly the radar and echo sounder, to help him evaluate potential hazards in the Liverpool Harbour approaches. To navigate safely, the person responsible for the conduct of a vessel must be constantly aware of his/her situation. That means he or she must be on the alert for signals and signs that provide important information, such as position, speed and hazards. After focussing all of his attention on one specific element (that is, finding presumed range lights), the master lost situational awareness and was unable to react to a dangerous situation that was gradually developing in front of him. Company Operating Procedures and Safety Management System The safe operation of a vessel, the safety of the crew and other occupants, and environmental safety require close cooperation and a healthy working relationship between shipboard personnel and the shipowner's personnel on shore. An effective safety management system must mobilize shipboard and shore managers, and must utilize the skills, attitudes and motivation of all concerned at every level. Non-convention vessels operating within Canadian waters are not required to have a full-scale safety management system, in compliance with the International Safety Management Code or other regulatory requirements. The need for non-convention ships to have a safety management system in place was recognized by several owners and charterers of Canadian vessels, who have voluntarily put such a system in place. The master's experience was limited to Dalhousie Harbour, greatly diminishing his ability to undertake this coastal voyage. The decision to enter Liverpool Harbour was influenced by a non-shipboard person, and no risk assessment was done before this decision was made. The approach to the entrance to Liverpool Bay was made without using a larger-scale chart, which was not available on the KetaV. The principles of bridge resource management were not applied. As the master was unassisted by the chief officer, he was relying solely on his own performance, foregoing the potential for team work and leaving little room for error. No members of the crew had been trained in bridge resource management, nor was that training mandatory.Findings as to Causes and Contributing Factors The master's experience was limited to Dalhousie Harbour, greatly diminishing his ability to undertake this coastal voyage. The decision to enter Liverpool Harbour was influenced by a non-shipboard person, and no risk assessment was done before this decision was made. The approach to the entrance to Liverpool Bay was made without using a larger-scale chart, which was not available on the KetaV. The principles of bridge resource management were not applied. As the master was unassisted by the chief officer, he was relying solely on his own performance, foregoing the potential for team work and leaving little room for error. No members of the crew had been trained in bridge resource management, nor was that training mandatory. Following this occurrence, the shipowner has placed on board its vessels an official document that is to be filled out by the crew with all pertinent details of equipment, safety equipment and procedures. The purpose of this documentation is to ensure that all crew members are aware of procedures and the functioning of all of the vessel's equipment. Also on board is a description of the role of each crew member, both as a watchkeeper and in emergency situations. A checklist is also provided, covering proper maintenance and inspections required on all equipment and machinery.Safety Action Taken Following this occurrence, the shipowner has placed on board its vessels an official document that is to be filled out by the crew with all pertinent details of equipment, safety equipment and procedures. The purpose of this documentation is to ensure that all crew members are aware of procedures and the functioning of all of the vessel's equipment. Also on board is a description of the role of each crew member, both as a watchkeeper and in emergency situations. A checklist is also provided, covering proper maintenance and inspections required on all equipment and machinery.